Risk factors in psychological resilience of patients receiving chemotherapy for lung cancer

Introduction

As a leading cause of global mortality, cancer exerts a profound impact on both patients and their families (1). With advancements in medical technology, the survival rates among cancer patients have gradually improved (2). However, challenges encountered during the treatment process, particularly the adverse effects associated with chemotherapy, pose a significant threat to patients’ physical and mental well-being (3). In this context, resilience has garnered considerable attention as it pertains to an individual’s active adaptation and recovery when faced with adversity (4).

Resilience encompasses an individual’s capacity to maintain mental health, prevent psychological disorders, and foster personal growth amidst life stressors and challenges (5). For cancer patients specifically, resilience not only influences their ability to adapt and respond to treatment but also directly impacts treatment outcomes and quality of life (6). A recent study on psychological resilience in the context of chemotherapy has highlighted its critical role in addressing the mental health challenges faced by cancer patients. Patients undergoing chemotherapy often face heightened psychological stress due to the physically taxing nature of treatment, uncertainty regarding outcomes, and potential social and financial burdens. Among these patients, individuals with pre-existing vulnerabilities, such as limited social support, comorbid mental health conditions, or advanced disease stages, are particularly at risk of diminished resilience. This reduced resilience can lead to adverse consequences, including poorer treatment adherence, lower quality of life, and heightened risk of depression or anxiety disorders. Current intervention strategies, such as cognitive-behavioral therapy, mindfulness-based stress reduction, and psychoeducational programs, have shown promise in improving resilience; however, challenges remain. These interventions often require significant time and resources, and their accessibility and effectiveness across diverse populations remain areas for further improvement and research. Research indicates that individuals exhibiting higher levels of resilience are more likely to actively confront disease-related challenges while demonstrating better treatment adherence and enhanced survival rates (7,8).

There is a notable lack of in-depth research focusing specifically on the psychological resilience of lung cancer patients undergoing chemotherapy—a group that faces a unique combination of physical, emotional, and social stressors. This study seeks to address this gap by comprehensively evaluating the psychological resilience of lung cancer patients undergoing chemotherapy and by discerning the multifaceted factors that significantly influence this resilience. Despite the growing recognition of the importance of psychological resilience in cancer care, there remains a lack of in-depth research specifically focused on lung cancer patients, who often face unique challenges due to the high symptom burden, stigma associated with the disease, and the physically and emotionally taxing nature of chemotherapy. Understanding these factors is essential not only for identifying patients at higher risk of psychological distress but also for guiding the development of targeted psychological interventions. Such interventions have the potential to bolster resilience, enhance treatment adherence, mitigate adverse psychological outcomes, and ultimately improve overall treatment efficacy and quality of life for lung cancer patients (4,9).

This research is therefore critical in filling an important gap in the literature and advancing the integration of mental health considerations into cancer care. Therefore, we conducted a cross-sectional study involving 200 lung cancer patients currently receiving chemotherapy. Utilizing a suite of psychometrically validated instruments, including Connor-Davidson Resilience Scale (CD-RISC) (9), the Generalized Self-Efficacy Scale (GSES) (10), Family Assessment Device (FAD), Ways of Coping Questionnaire (WCQ) (11), Cancer Quality of Life Questionnaire (QLQ-C30) (12), and Multidimensional Perceived Social Support Scale (MSPSS) (13), we captured a spectrum of demographic, psychological, and social factors. The application of multivariate logistic regression analysis allowed us to assess the interplay of these factors and their collective influence on psychological resilience (14). We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-9/rc).

Methods

Study design

The present study employed a retrospective cross-sectional design. The participants of this study comprised lung cancer patients who underwent chemotherapy at our hospital from January 2018 to January 2022. Inclusion criteria encompassed: (I) individuals aged between 18 and 65 years; (II) clinically diagnosed with stage IV lung cancer patients; (III) having received at least one course of chemotherapy [National Comprehensive Cancer Network (NCCN) guidelines recommend solutions]; (IV) possessing basic communication skills; (V) voluntary participation in the study; (VI) participants were required to have sufficient proficiency in Chinese to comprehend study materials and complete self-report questionnaires. Exclusion criteria included: (I) life expectancy less than 6 months; (II) diagnosis of other severe diseases such as cardiac, cerebral, or pulmonary disorders; (III) recurrent tumors. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of Shanghai Lung Cancer Center, Shanghai Chest Hospital, Shanghai Jiaotong University School of Medicine (No. IS25045). Informed consent was waived for this retrospective study due to the exclusive use of de-identified patient data, which posed no potential harm or impact on patient care.

Data collection

The CD-RISC consists of 25 items, each scored on a 5-point scale: 0 (not true at all), 1 (rarely true), 2 (sometimes true), 3 (often true), and 4 (true nearly all of the time). Respondents rate the items based on their experiences over the past month. The total score ranges between 0 and 100, with higher scores indicating stronger resilience (15). The median psychological resilience level (PRL) of the patients was 72, as measured by the CD-RISC scale. Based on this median score, patients were categorized into two groups: those with a CD-RISC score below 72 were classified as the low PRL group, and those with a score of 72 or above were classified as the high PRL group.

In addition to the CD-RISC, participants completed a battery of questionnaires designed to capture various potential influential factors on psychological resilience (16) (Supplementary Material 1, available at https://cdn.amegroups.cn/static/public/jtd-2025-9-1.pdf). These included:

GSES (17): GSES is a commonly used psychometric tool to assess an individual’s confidence in their own abilities in the face of difficulties or challenges. It emphasizes an individual’s overall belief in their ability to successfully complete a task or cope with a problem. There are 10 questions in total—1 score: completely incorrect; 2 marks: some are incorrect; 3 marks: some correct; 4 marks: exactly; 10–40 points: the higher the score, the stronger the sense of self-efficacy; a lower score indicates a lower sense of self-efficacy.

FAD (18): the FAD, comprises three core dimensions: responsibility, control, and challenge. This instrument consists of 20 items rated on a 4-point Likert scale: 1= strongly agree; 2= agree; 3= disagree; 4= strongly disagree. To ensure accurate scoring, items 1, 2, 3, 8, 10, 14, 16, 19, and 20 are reverse-coded. The total score spans from 20 to 80, with higher scores reflecting stronger family resilience. In the present study, the FAD demonstrated good internal consistency, with a Cronbach’s alpha of 0.80.

WCQ (11): WCQ is a questionnaire used to assess individuals’ coping strategies when faced with stress or difficult situations. The scale contains 66 questions and is divided into 8 dimensions: adversarial coping, self-control, seeking social support, accepting responsibility, avoidance, planned problem solving, positive reappraisal and escapism. The score is Likert 4-point scale (0–3 points). The scores on each dimension reflect which coping strategies individuals are more likely to use—problem-focused coping, such as planning to solve problems and seeking social support, they are more likely to actively solve problems; emotion-focused coping (emotion-focused coping), such as avoidance and emotional control, is more concerned with relieving emotional stress.

QLQ-C30 (12): QLQ-C30 is a questionnaire tool developed by the European Organization for Research and Treatment of Cancer (EORTC) to assess the quality of life of cancer patients. A total of 30 questions were divided into multiple functional scales, symptom scales and a general health scale. Likert scoring, usually on a scale of 1–4 or 1–7: functional scale and symptom scale—1 (none) to 4 (very much); overall health status scale—1 (very poor) to 7 (very good). The scores of each dimension are converted to 0–100 points according to the formula: function scale—the higher the score, the better the function; symptom scale—the higher the score, the more severe the symptom; overall health status scale—the higher the score, the higher the quality of life.

MSPSS (13): the MSPSS, is used to evaluate the level of social support perceived and utilized by individuals in daily life. It included three dimensions: objective support (e.g., tangible assistance such as financial aid, material help, or social participation), subjective support (e.g., emotional experience, a sense of being respected or understood), and support utilization (e.g., actively seeking help from family, friends, or professional services when needed). The scale consists of 10 items rated on a 4-point Likert scale, with total scores ranging from 0 to 40. Higher scores reflect greater levels of social support: scores below 20 indicate low support, 20–30 indicate moderate support, and scores above 30 indicate high support.

Statistical analysis

For data with homogeneity of variance, a t-test was utilized to compare the two groups. Measurement data that did not conform to a normal distribution were described using the median and quartiles, and differences between any two groups were compared using the Mann-Whitney test. Count data are presented as the number of cases and constituent ratio, and group differences were assessed using the Chi-squared test. Confounding factors were screened using univariate logistic regression analysis. Pearson correlation coefficient was employed to analyze the correlation between mental resilience level and other variables. Multivariate logistic regression analysis was conducted to evaluate the influencing factors of mental resilience. All statistical analyses were performed using R version 4.2.3, with a significance level set at P<0.05.

Results

Clinical characteristics of lung cancer patients

A total of 200 lung cancer patients undergoing chemotherapy were enrolled in this study, comprising 131 (65.5%) males and 69 (34.5%) females. The mean age was 58 (53.0, 62.0) years. The majority of the participants (74%) had attained a high school education or below, while a significant proportion (58.5%) had received more than five courses of chemotherapy. According to the CD-RISC, the median PRL of patients was 72 (59.75, 84.25) points. There were 98 (49%) patients in the low PRL group, and 102 (51%) patients in the high psychological resilience group. The characteristics of the included patients are presented in Table 1.

Compared to the low PRL group, the high PRL group demonstrated significantly elevated levels of GSES (P<0.001) and FAD (P=0.045). Moreover, there was a notable increase in WCQ scores (P=0.04), particularly in the domain of planful problem-solving among individuals with high PRL (P<0.001). Additionally, individuals with high PRL exhibited a significant enhancement in the MSPSS score (P=0.02), specifically within the objective support domain (P=0.004). The percentage of patients exhibiting moderate to high exercise intensity in the high PRL group was significantly greater than that observed in the low PRL group (P=0.03).

Single factor analysis of PRL

The potential positive factors for patients with high PRL included GSES, planful problem-solving and seeking social support in WCQ, objective support and MSPSS, and moderate to high exercise intensity. Univariate analysis showed that GSES, planned problem solving, seeking social support, multidimensional perceived social support (MSPSS), objective support and moderate to high intensity exercise had significant positive effects on the level of mental toughness (P<0.05). GSES [odds ratio (OR) =1.25], planned problem solving (OR =1.41), and seeking social support (OR =1.29) were important factors in improving resilience. In addition, the FAD, acceptance responsibility, QLQ-C30 scale, subjective support and treatment cycle showed marginal significance (0.05<P≤0.10), indicating that it may have some impact on mental toughness. The P values of gender, age, education level, monthly income, religious belief, family history of cancer, smoking history, drinking history and other factors were all greater than 0.05, showing no significant correlation (Table 2).

Correlation analysis of mental resilience level in patients with lung cancer after chemotherapy

The results illustrated in Figure 1 show a significant positive linear correlation between CD-RISC and GSES (R =0.605, P<0.001), FAD (R =0.229, P=0.001), QLQ-C30 (R =−0.163, P=0.02), and MSPSS (R =0.162, P=0.02). However, no significant linear correlation was observed between CD-RISC and WCQ (P=0.86).

Figure 1 Correlation analysis of PRL. (A) Correlation analysis between CD-RISC and GSES; (B) correlation analysis between CD-RISC and FAD; (C) correlation analysis between CD-RISC and QLQ-C30; (D) correlation analysis between CD-RISC and MSPSS; (E) correlation analysis between CD-RISC and WCQ. CD-RISC, Connor-Davidson Resilience Scale; FAD, Family Assessment Device; GSES, Generalized Self-Efficacy Scale; MSPSS, Multidimensional Perceived Social Support Scale; PRL, psychological resilience level; QLQ-C30, Cancer Quality of Life Questionnaire; WCQ, Ways of Coping Questionnaire.

Multivariate regression analysis of PRL in post-chemotherapy lung cancer patients

As depicted in Table 3, GSES [OR =1.28, 95% confidence interval (CI): 1.18–1.38, P<0.001], planful problem-solving (OR =1.34, 95% CI: 1.08–1.65, P=0.008), seeking social support (OR =1.40, 95%CI: 1.13–1.72, P=0.002), and objective support (OR =1.42, 95% CI: 1.08–1.87, P=0.01) emerged as significant positive predictors of mental resilience.

Discussion

The present study aimed to evaluate the level of psychological resilience and identify its influential factors among lung cancer patients undergoing chemotherapy. Utilizing a cross-sectional design and a comprehensive set of psychometric instruments, we found that the GSES, planful problem-solving, seeking social support and social objective support were significant positive predictors of psychological resilience.

The choice of indicators in this study was informed by an exhaustive review of the literature on psychological resilience within the context of cancer, underscoring the significance of self-efficacy, strategic coping mechanisms, and robust social support in managing the challenges of chemotherapy (19-21). The FAD and WCQ were included to provide a comprehensive view of the patients’ psychological resources and coping mechanisms (22). The QLQ-C30 and MSPSS were chosen to capture the multidimensional impact of cancer and its treatment on patients’ lives (10).

This study corroborates the critical importance of objective social support in enhancing psychological resilience. Social support not only provides emotional solace but also offers practical assistance and informational guidance to aid patients in coping with the stress and challenges associated with chemotherapy (22). Enhanced social support may strengthen psychological resilience by alleviating feelings of isolation and helplessness among patients, while simultaneously bolstering their confidence in disease management (10). Consequently, healthcare professionals should prioritize establishing and maintaining a robust social support system when treating individuals diagnosed with cancer (23). The present study also demonstrated the impact of coping strategies, specifically the ability to engage in planned problem-solving and actively seek social support, on resilience. It was found that employing positive coping strategies such as problem-solving and positive reconstruction can effectively assist patients in managing both physical and emotional reactions induced by chemotherapy (24). Conversely, avoidance coping strategies were associated with lower levels of resilience (25). These findings suggest that healthcare professionals should prioritize teaching patients effective coping skills through psychological interventions like cognitive-behavioral therapy to enhance their psychological adaptation abilities (26). In this study, GSES exerted a significant influence on the mental resilience of lung cancer patients following chemotherapy. Firstly, high levels of self-efficacy enable lung cancer patients to approach treatment challenges and difficulties with a positive mindset, thereby enhancing their mental resilience—the ability to recover and adapt during adversity (27). This optimistic outlook assists patients in better coping with the physical and psychological burdens associated with chemotherapy. Secondly, improving self-efficacy can alleviate perceived pressure among patients, boost their confidence in disease management, and enhance both their physical and mental well-being (28). During chemotherapy, this confidence and determination play a crucial role in ensuring treatment adherence and compliance (29). Moreover, self-efficacy interacts with other psychosocial factors that impact the mental resilience of lung cancer patients. For instance, social support and health literacy are significantly correlated with self-efficacy and indirectly affect patient quality of life through its effects on self-efficacy (30). Healthcare professionals should prioritize assessing and intervening in self-efficacy to assist lung cancer patients in effectively coping with the challenges posed by chemotherapy while enhancing their mental resilience and overall well-being (31).

Our findings align with the current scholarly discourse, which emphasizes the indispensable role of self-efficacy in the cultivation of resilience (26). High self-efficacy empowers patients to believe in their ability to manage their illness, which in turn, enhances their resilience (25). The positive association between planful problem-solving and resilience aligns with the theory that active coping strategies are beneficial in dealing with the challenges of chronic illnesses. While our results are in line with the study that has identified self-efficacy and social support as key factors in psychological resilience, they also extend current knowledge by highlighting the influence of demographic factors (22). Unlike the previous research that found gender to be a significant factor, our study indicates that exercise intensity is more predictive (30). This discrepancy may be attributed to differences in sample characteristics or cultural contexts.

A notable limitation inherent in this study is its cross-sectional design, which limits our ability to draw causal conclusions. Longitudinal studies are needed to understand the trajectory of psychological resilience over the course of chemotherapy and beyond. Additionally, the generalizability of our findings may be limited by the relatively homogenous sample, primarily consisting of patients from a single urban oncology center. Future research should aim to include a more diverse and representative group of lung cancer patients. In future studies, incorporating a qualitative component—such as interviews or focus groups—may provide deeper insights into the quantitative findings and offer a more comprehensive understanding of patients’ family resilience and social support experiences.

The findings of this study establish a foundation upon which future research can build, opening multiple avenues for further investigation. First, there is a need for longitudinal studies to examine the development and change in psychological resilience during and after chemotherapy. Second, interventions aimed at enhancing self-efficacy, problem-solving skills, and social support should be developed and tested for their effectiveness in improving resilience and quality of life. Third, the role of demographic factors in psychological resilience warrants further investigation, particularly in diverse and multicultural populations.

Conclusions

In summary, this study highlights the important role of self-efficacy, positive coping strategies (planned problem solving and social support seeking) and objective social support in the psychological resilience of lung cancer patients undergoing chemotherapy. These findings have important implications for the development and implementation of effective psychological interventions, which can serve as a basis for improving the mental health and quality of life of cancer patients.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-9/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-9/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-9/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-9/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of Shanghai Lung Cancer Center, Shanghai Chest Hospital, Shanghai Jiaotong University School of Medicine (No. IS25045). Informed consent was waived for this retrospective study due to the exclusive use of de-identified patient data, which posed no potential harm or impact on patient care.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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